Mosaicism in neurofibromatosis type 2: an update of risk based on uni/bilaterality of vestibular schwannoma at presentation and sensitive mutation analysis including multiple ligation-dependent probe amplification

BACKGROUND

Neurofibromatosis type 2 (NF2) is almost unique among inherited disorders in the frequency of mosaicism in the first affected generation. However, the implications of this on transmission risks have not been fully elucidated.

METHODS

The expanded database of 460 families with NF2 and 704 affected individuals was analysed for mosaicism and transmission risks to offspring.

RESULTS

64 mosaic patients, with a projected mosaicism rate of 33% for sporadic classical NF2 with bilateral vestibular schwannoma at presentation and 60% for those presenting unilaterally, were identified. Offspring risks can be radically reduced on the basis of a sensitive mutation analysis of blood DNA including multiple ligation-dependent probe amplification (MLPA, which detects 15% of all mutations), but even MLPA cannot detect high levels of mosaicism.

CONCLUSION

The chances of mosaicism in NF2 and the resultant risks of transmission of the mutation to offspring in a number of different clinical situations have been further delineated. The use of MLPA in this large NF2 series is also reported for the first time.

Should NF2 mutation screening be undertaken in patients with an apparently isolated vestibular schwannoma?

Early onset of vestibular schwannoma (VS) is associated with the inherited condition neurofibromatosis type 2 (NF2). However, the majority of NF2 presents bilaterally and the proportion of early-onset apparent sporadic unilateral VS because of NF2 remains to be determined. We have determined the risk by studying NF2 risk in a population-based set of VS, looking at the mode of presentation in a large NF2 data set and the outcome of NF2 mutation analysis in 148 sporadic unilateral VS. The risk of NF2 in an apparently sporadic case of unilateral VS is small apart from in the very youngest age group (<20 years). NF2 germ line mutation testing is unlikely to reveal a mutation except <20 years as a result of the low risk and high rates of mosaicism. Germ line mutation testing is probably only justified in sporadic unilateral VS <20 years unless other features of NF2 are present. Ideally mutation testing should start with the original tumour specimen.

Cell swelling, seizures and spreading depression: an impedance study

The cellular processes that take place during the transition from pre-seizure state to seizure remain to be defined. In this study in awake, paralyzed rats, we used an electrical impedance measure of changes in extra-cellular intracranial volume to estimate changes in cell size in acute models of epilepsy. Animals were prepared with extradural electroencephalographic (EEG)/impedance electrodes and a venous catheter. On a subsequent day, animals were paralyzed, ventilated and treated with picrotoxin, kainic acid or fluorocitrate in doses that usually induce epileptiform discharges. We now report that increases in baseline impedance were induced by kainic acid and smaller increases by picrotoxin. We also demonstrated that epileptiform discharges were preceded by small, accelerated increases in impedance. Increases in baseline impedance were highly correlated with increases in power of non-ictal high frequency EEG activity. Seizures were accompanied by increases in impedance and all treatments induced transient, relatively large, increases in impedance often associated with unilateral reductions in low frequency EEG, likely periods of spreading depression. We conclude: cerebral cells swell in convulsant models of epilepsy, that there are pre-ictal accelerations in cell swelling, and that spreading depression-like events are frequently associated with seizures.

The aldosterone synthase (CYP11B2) and 11beta-hydroxylase (CYP11B1) genes are not expressed in the rat heart

Aldosterone synthase (CYP11B2) and 11beta-hydroxylase (CYP11B1) catalyze the production of aldosterone and corticosterone, respectively, in the rat adrenal cortex. Recently, there has been some debate as to whether these corticosteroids are also produced in the hearts of rodents and humans, possibly contributing to the development of hypertrophy and myocardial fibrosis. To investigate this, we have used our established, highly sensitive real-time quantitative RT-PCR method to measure CYP11B1 and CYP11B2 mRNA levels in adrenal and cardiac tissue from several rat models of cardiovascular pathology. We have also studied isolated adult rat ventricular myocytes treated with angiotensin II and ACTH. Total RNA was isolated from the adrenal and cardiac tissue of 1) male Wistar rats with heart failure induced by coronary artery ligation and sham-operated controls; 2) stroke-prone spontaneously hypertensive rats and Wistar Kyoto rats as controls; 3) cyp1a1Ren-2 transgenic rats and Fischer controls; 4) isolated adult Sprague-Dawley ventricular myocytes incubated with 11-deoxycorticosterone (DOC), DOC plus angiotensin II, or DOC plus ACTH. Adrenal CYP11B2 expression was significantly increased in transgenic rats compared with Fischer controls (1.3 x 10(9)+/- 1.2 x 10(9) vs. 2.1 x 10(7) +/- 7.0 x 10(6) copies/microg RNA; P < 0.05). There were no other significant differences in adrenal CYP11B2 or CYP11B1 expression between the model animals and their respective controls. Cardiac CYP11B1 and CYP11B2 mRNA transcript levels from all in vivo and in vitro groups were never greater than 100 copies per microgram total RNA and therefore too low to be detected reproducibly. This suggests that cardiac corticosteroid production is unlikely to be of any physiological or pathological significance.

Functional capacity evaluation as a performance measure: evidence for a new approach for clients with chronic back pain

OBJECTIVES

To report the research and development of a new approach to Functional Capacity Evaluation, the Gibson Approach to Functional Capacity Evaluation (GAPP FCE) for chronic back pain clients.

METHODS

Four studies, including pilot and feasibility testing, expert review, and preliminary interrater reliability examination, are described here. Participants included 7 healthy young adults and 19 rehabilitation clients with back pain who underwent assessment using the GAPP FCE. Thirteen therapists were trained in the approach and were silently observed administering the Functional Capacity Evaluations by at least 1 other trained therapists or the first investigator or both. An expert review using 5 expert occupational therapists was also conducted.

RESULTS

Study 1, the pilot with healthy individuals, indicated that the GAPP FCE was a feasible approach with good utility. Study 2, a pilot using 2 trained therapists assessing 5 back pain clients, supported the clinical feasibility of the approach. The expert review in Study 3 found support for GAPP FCE. Study 4, a trial of the approach with 14 rehabilitation clients, found support for the interrater reliability of recommendations for return to work based on performance in the GAPP FCE.

DISCUSSION

The evidence thus far available supports the GAPP FCE as an approach that provides a sound method for evaluating the performance of the physical demands of work with clients with chronic back pain. The tool has been shown to have good face and content validity, to meet acceptable test standards, and to have reasonable interrater reliability. Further research is occurring to look at a larger interrater reliability study, to further examine content validity, and to examine predictive validity.

Recommendations for a technical quality control program for diagnostic X-ray equipment

This position paper was produced by a working party set up by the Radiology Special Interest Group of the ACPSEM in 2001. It is designed to give the consensus view of College members in Australia and New Zealand on the nature and frequency of tests which should be performed on diagnostic x-ray equipment to maintain adequate quality control of imaging performance and radiation safety. Tests on mammographic equipment have been excluded having been covered in a previous ACPSEM position paper (Australas Phys Eng Sci Med, 24(3):107-131, 2001). Detailed descriptions of test procedures are not given but it is intended that a series of workbooks should be produced giving College recommended test methods for each imaging modality. The recommendations are produced here in an easy-to-read, tabular form giving the nature and purpose of each test and the implications of non-compliance with regard to image quality and radiation safety.

Cerebral palsy and socioeconomic status: a retrospective cohort study

AIMS

To study the relation between risk of cerebral palsy and socioeconomic status.

METHODS

A total of 293 children with a diagnosis of cerebral palsy out of 105,760 live births between 1 January 1982 and 31 December 1997 were identified from the special conditions sub-file of the West Sussex Computerised Child Health System.

RESULTS

There was a linear association between risk of cerebral palsy and socioeconomic status (SES) measured by the Registrar General's social class (RGSC) and enumeration district (ED) ranked into quintiles by the Townsend Deprivation Index derived from 1991 census data. Fifty one per cent and 30% of cases of cerebral palsy were statistically "attributable" to inequality in SES using the RGSC and ED quintile respectively. A linear association was also noted for singleton live births. The association between risk of cerebral palsy and ED quintile persisted in a logistic regression model that included birth weight and gestational age, although that between RGSC and cerebral palsy no longer reached conventional levels of statistical significance after adjustment.

CONCLUSIONS

A strong association was observed between socioeconomic status and the risk of cerebral palsy, which was only partly accounted for by the known social gradients in birth weight and gestational age.

Identification of recurrent regions of chromosome loss and gain in vestibular schwannomas using comparative genomic hybridisation

BACKGROUND

Schwannomas are benign tumours of the nervous system that are usually sporadic but also occur in the inherited disorder neurofibromatosis type 2 (NF2). The NF2 gene is a tumour suppressor on chromosome 22. Loss of expression of the NF2 protein product, merlin, is universal in both sporadic and NF2 related schwannomas. The GTPase signalling molecules RhoA and Rac1 regulate merlin function, but to date only mutation in the NF2 gene has been identified as a causal event in schwannoma formation.

METHODS

Comparative genomic hybridisation (CGH) was used to screen 76 vestibular schwannomas from 76 patients (66 sporadic and 10 NF2 related) to identify other chromosome regions that may harbour genes involved in the tumorigenesis.

RESULTS

The most common change was loss on chromosome 22, which was more frequent in sporadic than in NF2 related tumours. Importantly, eight tumours (10%) showed gain of copy number on chromosome 9q34. Each of the two NF2 patients who had received stereotactic radiotherapy had non-chromosome 22 changes, whereas only one of eight non-irradiated NF2 patients had any chromosome changes. Three tumours had gain on 17q, which has also been reported in malignant peripheral nerve sheath tumours that are associated with neurofibromatosis type 1. Other sites that were identified in three or fewer tumours were regions on chromosomes 10, 11, 13, 16, 19, 20, X, and Y.

CONCLUSIONS

These findings should be verified using techniques that can detect smaller genetic changes, such as microarray-CGH.

Substrate specificity and inducibility of TACE (tumour necrosis factor α-converting enzyme) revisited: the Ala-Val preference, and induced intrinsic activity

Tumour necrosis factor α (TNFα)-converting enzyme (TACE/ADAM-17, where ADAM stands for a disintegrin and metalloproteinase) releases from the cell surface the extracellular domains of TNF and several other proteins. Previous studies have found that, while purified TACE preferentially cleaves peptides representing the processing sites in TNF and transforming growth factor α, the cellular enzyme nonetheless also sheds proteins with divergent cleavage sites very efficiently. More recent work, identifying the cleavage site in the p75 TNF receptor, quantifying the susceptibility of additional peptides to cleavage by TACE and identifying additional protein substrates, underlines the complexity of TACE-substrate interactions. In addition to substrate specificity, the mechanism underlying the increased rate of shedding caused by agents that activate cells remains poorly understood. Recent work in this area, utilizing a peptide substrate as a probe for cellular TACE activity, indicates that the intrinsic activity of the enzyme is somehow increased.

Isolation and isotope labeling of cysteine- and methionine-containing tryptic peptides: application to the study of cell surface proteolysis

Inexpensive methods were developed for isolating and isotopically labeling tryptic peptides that contain either cysteine or methionine. After covalently capturing cysteine-containing peptides with pyridyl disulfide reactive groups on agarose beads, extensive wash steps were applied, and the attached peptides were released using a reducing agent. This approach results in less nonspecifically bound peptides and eliminates the possibility of generating avidin peptide background ions that can arise when using methods based on biotin and avidin (e.g. isotope-coded affinity tag). The thiols were alkylated using either N-ethyl- or N-D5-ethyl-iodoacetamide, both of which can be synthesized in a single step using inexpensive reagents. This isotopic labeling does not greatly increase the peptide mass, nor does it affect the peptide ion charge state in electrospray ionization. In addition, methionine-containing peptides were captured using commercially available methionine-reactive beads, and relative quantitation of peptides was achieved by isotopic labeling of amino groups using activated esters of either nicotinic acid or D4-nicotinic acid. These methods were used to study the metalloprotease-mediated shedding of cell surface proteins from a mouse monocyte cell line that had been treated with a phorbol ester and lipopolysaccharide. In addition to the identification of proteins previously determined to be inducibly shed, three new shed proteins were identified: CD18, ICOS ligand, and tumor endothelial marker 7-related protein.

Two unique patients with trisomy 18 mosaicism and molecular marker studies

We report two unusual patients with trisomy 18 mosaicism presenting with minor anomalies and failure to thrive in the first year of life. Chromosome analysis showed trisomy 18 in 30/30 peripheral blood lymphocytes in both children. Analysis of skin fibroblasts in the first child showed normal female chromosomes in 30/30 cells, and the fibroblast karyotype in the second child showed mosaicism for tetrasomy 18p, trisomy 18, and normal female chromosomes (karyotype 47,XX, +i(18)(p10)[47]/47,XX, +18[9] /46,XX[4]). Trisomy 18 commonly results from nondisjunction at maternal meiosis II (MII). Nondisjunction at maternal MII has also been postulated to be the initial step in the formation of tetrasomy 18p. In our second case, the additional chromosome 18 was the result of maternal nondisjunction at MII, consistent with this hypothesis. In the first case, nondisjunction at maternal meiosis I (MI) was responsible for the extra chromosome 18.

Intrafamilial correlation of clinical manifestations in neurofibromatosis 2 (NF2)

Measuring correlation in clinical traits among relatives is important to our understanding of the causes of variable expressivity in Mendelian diseases. Random effects models are widely used to estimate intrafamilial correlations, but such models have limitations. We incorporated survival techniques into a random effects model so that it can be used to estimate intrafamilial correlations in continuous variables with right censoring, such as age at onset. We also describe a negative-binomial gamma mixture model to determine intrafamilial correlations of discrete (e.g., count) data. We demonstrate the utility of these methods by analyzing intrafamilial correlations among patients with neurofibromatosis 2 (NF2), an autosomal-dominant disease caused by mutations of the NF2 tumor-suppressor gene. We estimated intrafamilial correlations in age at first symptom of NF2, age at onset of hearing loss, and number of intracranial meningiomas in 390 NF2 nonprobands from 153 unrelated families. A significant intrafamilial correlation was observed for each of the three features: age at onset (0.35; 95% confidence interval (CI) 0.23-0.47), age at onset of hearing loss (0.51; 95% CI, 0.35-0.64), and number of meninginomas (0.29; 95% CI, 0.15-0.43). Significant correlations were also observed for age at first symptom within NF2 families with truncating mutations (0.41; 95% CI, 0.06-0.68) or splice-site mutations (0.29; 95% CI, 0.03-0.51), for age at onset of hearing loss within families with missense mutations (0.67; 95% CI, 0.18-0.89), and for number of meningiomas within families with splice-site mutations (0.39; 95% CI, 0.13-0.66). Our findings are consistent with effects of both allelic and nonallelic familial factors on the clinical variability of NF2.

A common KIR2DS4 deletion variant in the human that predicts a soluble KIR molecule analogous to the KIR1D molecule observed in the rhesus monkey

A KIR2DS4 deletion variant allele, previously identified through KIR PCR-SSOP typing studies, was characterized, alongside a normal KIR2DS4 allele, by cDNA cloning and sequencing and its prevalence in the population determined using a deletion specific probe. The KIR2DS4 deletion variant was found in 72 of the 90 individuals screened and differed from the normal KIR2DS4 sequence by a single 22 bp deletion in exon 5. The deletion causes a frameshift predicting a truncated KIR2DS4 protein with a significantly altered D2 domain that would be secreted due to the loss of the transmembrane/cytoplasmic domains. Parallels with a recent study in the rhesus monkey highlighting access to the same open reading frame as the deletion variant, also predicting a soluble KIR molecule, are drawn.

Molecular genetic analysis of the NF2 gene in young patients with unilateral vestibular schwannomas

Neurofibromatosis type 2 (NF2) must be suspected in patients presenting with a unilateral vestibular schwannoma at a young age who are therefore at theoretical risk of developing bilateral disease. We identified 45 patients aged 30 years or less at the onset of symptoms of a unilateral vestibular schwannoma. Molecular genetic analysis of the NF2 gene was completed on peripheral blood samples in all 45 and on 28 tumour samples. No pathogenic NF2 mutations were identified in any of the blood samples. NF2 point mutations were identified in 21/28 (75%) tumour samples and loss of heterozygosity (LOH) in 21/28 (75%) tumour samples. Both mutational hits were identified in 18/28 (65%) tumour samples. In one multilobular tumour, one (presumably first hit) mutation was confirmed which was common to different foci of the tumour, while the second mutational event differed between foci. The molecular findings in this patient were consistent with somatic mosaicism for NF2 and the clinical diagnosis was confirmed with the presence of two meningiomas on a follow up MRI scan. A further patient developed a contralateral vestibular schwannoma on a follow up MRI scan in whom neither of the truncating mutations in the vestibular schwannoma were present in blood. It is important when counselling patients with unilateral vestibular schwannomas to identify (1) those at risk of bilateral disease, (2) those at risk of developing other tumours, and (3) other family members at risk of developing NF2. Comparing tumour and blood DNA cannot exclude mosaicism in the index case and cannot, therefore, be used to predict those at risk of developing further tumours. However, identification of both mutations or one mutation plus LOH in the tumour and exclusion of those mutations in the blood samples of the sibs or offspring of the affected case may be sufficient to render further screening unnecessary in these relatives.

Studies on parasitemia courses and mortality in mice infected with genetically distant Trypanosoma cruzi clonets

The biological characterization of bloodstream forms of eleven Trypanosoma cruzi cloned stocks, corresponding to two genetically similar clonets (19 and 20) and one distant clonet (39), according to multilocus enzyme electrophoresis analysis, showed dissimilar parasitemia in an experimental isogenic mouse model. While clonet 39 stocks gave low parasitemias, clonets 19 or 20 stocks gave high parasitemias, independently of the inocula (10(2) and 10(4) bloodstream forms) used. High parasitemia did not always associate with greater mortality. Statistical studies on mortality using a low inocula showed significantly higher mortality with clonet 39 stocks when compared to clonets 19 or 20 stocks. Finally, in order to confirm the identity of each stock studied, typing by molecular karyotype was performed before inoculating mice.

Manual removal of the placenta--a case control study

The aim of this study was to determine the incidence and complications related to manual removal of the placenta in a regional hospital in Australia. The study was carried out at the Goulburn Valley Base Hospital in Shepparton. The hospital medical records were reviewed from 1992 to 1999. A total of 3734 singleton live vaginal deliveries took place during the 7-year study period. The placenta was removed manually in 114 women (3%). For a control group, a series of 113 women who had singleton live vaginal deliveries from the same period were chosen at random. The case and control groups were similar in age, parity, and gravidity. A previous history of retained placenta and a history of preterm delivery in the current pregnancy were significantly related to retained placenta (OR 9.8 [95% CI 1.1-85.5] and OR 5.6 [95% CI 1.1-26.8], respectively). The cases received significantly more blood transfusions than the control group (13% versus 0%). Decreased maternal age was also significantly related to retained placenta. There were also more post-delivery dilatation and curettage (D&C) operations and diagnosis of endomyometritis in the case group. However, these differences were not statistically significant. One woman, in the case group, had to have a hysterectomy due to placenta accreta.

Identification of Trypanosoma cruzi genotypes circulating in Chilean chagasic patients

Parasite DNA amplified by PCR from blood of 73 chagasic children and adults of two endemic areas of Chile were studied by Southern blot and/or dot blot hybridization analysis with a panel of three minicircle probes corresponding to the parasite genotypes (clonets 19, 33 and 39). The hybridization pattern of the PCR positive samples identified clonets 39, 19/20, and 32/33 with frequencies of 0.84, 0.32 and 0.26, respectively. A total of 31 samples corresponded to mixed infections. The most frequently found mixtures were: clonets 39 and 19/20 (14 cases), followed by clonets 39 and 32/33 (8 cases), clonets 39, 32/33 and 19/20 (8 cases), and clonets 32/33 and 19/20 (1 case). Amplified DNA from 9 cases showed no hybridization signal with none of the three studied probes indicating that other genotypes different to the ones mentioned are circulating in humans, but that the clonets used as probes are the most prevalent ones in terms of transmission in the endemic areas studied. A biological characterization of 34 T. cruzi populations isolated from the xenodiagnosis of the patients was performed on an experimental murine model. The biochemical characterization of the parasite populations by molecular karyotype determined that the most frequent parasite isolated from patients belongs to clonet 39.